Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS 1950 Port Road A CITY/ZIP Stockton/95203 m <br /> D <br /> CROSS STREET Port Road 2 APN 14502004 PARCEL SIZE 162 acre�LAND USE APPLICATION# <br /> lam,m�Lin <br /> m <br /> OWNER NAME L/C�[�JN PHONE <br /> OWNER ADDRESS �D Vy/`� �i�'T] / CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder PHONE 209.948.1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/ZIP Stockton/CA/95206 <br /> SUBCONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714.633.5025 <br /> SUBCONTRACTOR ADDRESS 954 North Lemon Street CITY/STATE/ZIP Orange/CA/92867 <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 899451 EXPIRATION DATE 06/30/2019 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE r1 Domestic/Private ❑ Irrigation/Agricultural n Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br /> Li Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical 2 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool X Push Point ❑ Other <br /> Proposed Well Depth 100 ft Excavation 1.5 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft X Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped X Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Project Geologist DATE 1/22/2019 <br /> r <br /> Rom <br /> z <br /> .. — Wui <br /> Q <br /> ITs 9 / A - On <br /> z <br /> � <br /> D PA T tM E N T S E ,ONLY ,/� <br /> Application Accepted By Dae Area Employee ID#i� �`� <br /> Grout Inspection By Date CI SPECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />